Provider Demographics
NPI:1093982480
Name:JOHNSON, GWEN A (PHD, BCBA, LBA)
Entity Type:Individual
Prefix:DR
First Name:GWEN
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5980 S DURANGO DR STE 131
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-1775
Mailing Address - Country:US
Mailing Address - Phone:614-783-4936
Mailing Address - Fax:
Practice Address - Street 1:8043 CORPORATE CIR STE 1
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-1279
Practice Address - Country:US
Practice Address - Phone:614-783-4936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-05-2208103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst